1. Menopause is caused by the depletion of ovarian follicles leading to a decline in estrogen levels, and can also result from surgical removal of the ovaries and uterus. 2. Estrogen plays an important role in many bodily functions beyond reproduction, including brain and psychological health, temperature regulation, bone and heart health, and more. 3. Hormone replacement therapy is often used to treat discomforting menopause symptoms, but its use requires consideration of risks like increased chances of blood clots, stroke, and certain cancers. Alternative treatments include progesterone, gabapentin, SSRIs, and herbal remedies.

1. KEY POINTS in prescription writing in
MENOPAUSE
DR. SHARDA JAIN
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar

2. Biological clock never stops

3. Menopause Prescription
Update

4. ?

5. Root Cause
1.Follicular depletion
2.Surgical removal of uterus and ovaries known as
Hysterectomy& Oophorectomy ("induced, or
surgical," menopause).
Menarche 40 yrs 45 yrs

6. Transition
Estrogen steady state Estrogen fluctuation &depletion

7. Role of Estrogen
Brain :Helps to maintain psychological well being
Vasomotor: Regulates normal temperature &
perspiration
Liver: Helps to regulate fat metabolism and
distribution
of fat
Bone: Helps to maintain bone mineral density
Heart : Regulates Cholesterol metabolism
Maintains the right ratio of LDL and HDL
Skin: Helps in collagen synthesis & maintain skin
integrity
In non reproductive organs

8. Breast: Helps in the healthy development of
breast tissues
Uterus: Helps to repair the endometrium &
prepare the uterus for fetus
development
Urogenital: Helps to maintain a lubricated&
thick vagina
Maintains the integrity of
urethral epithelium
Other Role of Estrogen
In Reproductive Organs

9. MENOPAUSE

10. Medical Management of
menopause symptoms

11. Health Issues
o Cancer risk in breast & Endometrium
o Stroke
o CVD
o Osteoporosis &
o Discomforting symptoms

12. Discomforting Symptoms
The Kupperman index is a numerical conversion index and covers
the above menopausal symptoms
1 Vaginal dryness
2 Hot flashes& night Sweats
3 Paresthesia
4 Insomnia
5 Nervousness
6 Melancholia
7 Dizziness
8 Fatigue
9 Arthritic Pain
10 Formication
11 Palpitation
12 Headache

14. Medical Management
• Hormone Replacement Therapy
• Alternatives:
1. Progesterone
2. Delta-adrenergic drugs (Clonidine)
3. Gabapentin
4. SSRI (venlafaxine and paroxetine)
5. Phytoestrogens
6. Steroids (DHEA and progesterone creams)
7. Tibolone (Livial)
8. Selective Oestrogen Receptor Modulators (tamoxifen,
raloxifene)
9. Herbals

15. HRT in Menopause

16. Hormone Replacement
Therapy
• Should be taken to
preserve bone mass
• HRT probably
prevents dementia
• Relieves the symptoms
of menopause

17. HRT-Limitations

18. Recent Update on HRT
HRT increases risk of blood clots and stroke, finds new analysis
• HRT offers women no protection against having or dying from
a myocardial infarction
• increasing the risk of blood clots and stroke
….. a new analysis published by the Cochrane Collaboration
has shown
• Ref: Boardman HMP, Hartley L, Eisinga A, et al. Hormone therapy
for preventing cardiovascular disease in post-menopausal
women. Cochrane Database Syst Rev 2015;3

19. Progesterone
• Women with a uterus or who had previous
ENDOMETRIOSIS need endometrium protection by using a
minimum of 10-12 days per cycle of a progesterone
• In the first 12-18 months after menopause should be on
cyclical therapy (to prevent break-through bleeding).
• Reduce the number and severity of hot flushes by up to 85%
• Medroxyprogesterone Acetate (MPA) alternatively depo
provera

20. Clonidine
• Delta-adrenergic drug originally developed to treat
HYPERTENSION, relieves hot flushes by reducing
peripheral vascular reactivity
• Mean reduction 40% (placebo 30%)
Limitations
S/e: orthostatic hypotension, headaches, fatigue,
nausea, constipation, dry mouth
Should be avoided in women with significant
depression

21. Gabapentin
• Used in treatment of epilepsy, migraine, tremor and
neuropathic pain
• 50-60% of control of hot flushes (vs 30% placebo)
Limitations
• ? Effect on hypothalamus with reduction in calcium
currents
• S/e light headedness, sleepiness and fatigue
• Should be tapered down

22. Steroids (Androgen Therapy)
• There is a positive benefit to add back testosterone
in some surgically or naturally menopausal women
• Behavioural intervention also improves sexual
function
Limitations
• Side effects
• No known long term safety profile
• None licensed in Australia

23. Tibolone
STEARs – Selective Tissue Estrogenic Activity Regulators
(oestrogenic,
androgenic and progestogenic properties)
Limitations
• Less effective than conventional HRT in reducing hot flushes
(Cochrane 2012)
• Can be used to improve libido (but risk of VTE)
• Not safe in breast cancer survivors (LIBERATE)
• Does not need endometrium protection

24. Herbals
Limitations
• Evening primrose – may be effective for
breast tenderness (not for flushes)
• Cong quai, ginkgo biloba,
ginseng, not better than
placebo

25. Current Treatment
options

26. Symptom Relief Treatments
• Cardiovascular risk: lifestyle modifications (diet, non-
smoking and exercise, BP and cholesterol control)
• Flushes: may be reduced with SSRIs, high dose
progestogens, clonidine, gabapentin or herbals
• Osteoporosis: calcium, exercise and bisphosphonates
• Urogenital atrophy: vaginal moisturising preparations
+/- topical oestrogens

27. Limitations
• Taking too many medicines
• Relief only for Short term
• Expensive as more medicines to buy

28. Indications for estrogen therapy /estrogen
progestogen therapy
• The most effective treatment for
vasomotor symptoms is HT
Evidence – Based
(Grade A).

29. Indications for estrogen therapy /estrogen
progestogen therapy
• Progestogens or low dose oral contraceptive pills
can be used in the
Menopause Transition Phase for relief of
symptoms.
Evidence – Based
(Grade A)

30. • Vaginal estrogen therapy is most effective in
the treatment of
• Low dose vaginal preparations are as
effective as systemic therapy.
• Some women on oral estrogen therapy may
require additional local therapy
UROGENITAL ATROPHY
Urogential Atrophy.
(Grade A)

31. • Recurrent attacks of atrophic virginities
require the use of the smallest effective dose
over a period of time. After control of acute
symptoms, the dose of local estrogen can be
tapered for long-term maintenance therapy.
Treatment may be continued indefinitely,
although safety data from studies do not go
beyond one year.
ATROPHIC VIRGINITIES
(Grade C).

32. • Recurrent urinary tract infections
in this age after ruling out other
causes may benefit from the local
application of ET.
Recurrent Urinary Tract
Infections
(Grade A)

33. • Hormone therapy should not be started solely for
bone protection after 10 years of menopause.
• Extended use of HT in women with reduced bone
mass is an option after considering the risk benefit
analysis compared with the other available
therapies for osteoporosis.
• The bone protective effecft is lost after stopping HT.
Osteoporosis
(Grade B)

34. • Hormone therapy should be offered to
women with premature ovarian failure
or early menopause and it can be
recommended until the age of natural
menopause.
Premature Ovarian Failure
(Grade C)

35. • Estrogen can be prescribed to enhance
mood in women with depressive
symptoms. The effect appears to be
greater for perimenopausal
symptomatic women than for
postmenopausal women.
Depression
(Grade A)

36. Precautions to be taken while
prescribing HT are as follows :
• Progestogen in adequate dose should be
supplemented along with oral estrogens in
women with uterus (Grade A)
• Estrogen alone is given in hysterectomized
women (Grade A)

37. • Progestogen supplement for endometrial
protecftion is not needed along with the use of
vaginal estrogen
(Grade C)
• Endometrial surveillance is not necessary in low
risk asymptomatic woman.
• Unscheduled bleeding should be investigated by
an ultrasound and endometrial biopsy
(Grade A )
Precautions

38. • A full gynecological assessment is
mandatory prior to starting HT and at
regular intervals thereafter.
• Self breast examination is advised
monthly and clinical breast examination
at least annually. A mammogram
/ultrasound wherever available should be
carried out 1-3 yearly if the initial
mammogram is normal
(Grade C).

39. Key points
1. The art of prescibing HT is to use the
minimum effective dose judiciously on
indication, after appropriate counseling.
Maximum benefits, minimum side effects
can be achieved by judicious use of HT.
2. Ideally therapy begins within 10 years of
menopause or below 60 years of age
window of opportunity.

40. 3. Use low – dose estrogen with low dose
progestogen when appropriate .
4. Transversal administration had reduced
risk of venous thrombo embolism
compared with oral administration.
Key points
ISO 14001:2004 (EMS)
…..Caring hearts, healing hands

41. 5. Side – effect profile of various progestins may
play critical role in selecting the optimum
treatment regimen. Natural progesterone is
choice.
6.Individualize hormone therapy, i.e. the dose,
type, route according to the need of the
indidual woman .
Key points of prescription using HRT

42. 8. Unopposed estrogen (ET) is given for
women with hysterectomy
9. Progesterone needs to be added for
women with uterus.
10. Tibolone had selective estrogenic,
progestogenic and androgenic
properties.
ISO 14001:2004 (EMS)
…..Caring hearts, healing hands

43. COMMON PRESCRIPTIONS
For relief of menopausal symptoms
•Lifestyle modifications,
•Tab. Calcium carbonate 1000 mg
with Vitamin D

44. Estrogen therapy for
HYSTERECTOMISED patients.
• Tab. CEE 0.3 mg , 0.625 mg /
• Estradiol valerate 1,2 mg daily HS
• Tab. Tibolone 2.5 mg daily
COMMON PRESCRIPTIONS

45. Abnormal menopause (POF)
• Cyclic – Sequential estrogen
progestogen therapy till the age of
natural menopause.
• 17 βestradiol 1 mg + dydrogeterone 10
mg (Semiston 1-10 ,
• Low dose oral contraceptive pill may
be used till the natural age of
menopause if not contraindicated

46. Cyclic sequential
• CEE 0.3 mg, 0.625 mg – 1 -25 days +
Medroxy progesterone acetate 2.5
mg, preparation not availble) 10mg or
progesterone 200 mg 10 – 14 days
Estrogen progestogen therapy
in women with uterus in the
peri and early menopause

47. EPT in women with uterus in the
postmenopausal patients
(after one year of amenorrhea )
• CEFE 0.3 mg, 0.625 mg daily
+Progesterone 100 mg daily
• 17 β estradiol 1 mg + dydrogesterone 5
mg (Semiston ]
• Tibolone 2.5 mg daily

48. MANAGEMENT OF SIDE EFFECTS OF
HORMONE THERAPY
SIDE
EFFECTS
STRATEGY
Fluid
Retention
Restrict salt intake; maintain adequate water intake;
exercise; try a herbal diuretic or mild prescription
diuretic.
Bloating Switch to low-dose transdermal estrogen; lower the
progestogen dose to a level that still protects the
uterus ; switch to another progestin or to micronized
progesterone.
Breast
Tenderness
Lower the estrogen dose; switch to another estrogen;
restrict salt intake; switch to another progestin; cut
down on caffeine and chocolate.

49. SIDE
EFFECTS
STRATEGY
Headaches Switch to transdermal estrogen; lower the dose of
estrogen and/or progestogen; switch to a continuous-
combined regime; switch to progesterone or 19-
nopregnane derivative; ensure adequate water intake;
restrict intake of salt, caffeine and alcohol.
Mood
Change
Lower the progestogen dose; switch progestogen;
switch from systematic progestin to the progestin IUS;
change to a continuous-combined EPT regimen; ensure
adequate water intake; restrict intake of a salt, caffeine
and alcohol
Nausea Take oral estrogen tablets with meals or before bed;
switch to another oral estrogen; switch to transdermal
estrogen; lower the estrogen or progestogen dose

50. Hormone Therapy in PRE-EXISTING diseases
Condition Hormone Therapy
Asthma Small increase in risk, no worsening of pre-
existing diseases
Breast Cancer Vaginal estrogen not contraindicated
Cervical
Cancer and
Dysplaia
Not contraindicated
Coronary
heart diseases
for secondary
prevention
Should not be initiated

51. Condition Hormone Therapy
Crohn’s/Coeliac
Diseases
Increased risk osteoporosis,
transdermal route preffered
to enhance absorption
Diabetes
mellitus
Increased risk osteoporosis,
not contraindicated
Endometrial
Cancer
Not contraindicated

52. Condition Hormone Therapy
Endometriosis Small increase in risk of diseases
reactivation, but evidence poor
Fibroids Can cause enlargement but evidence poor
Ovarian
cancer
Not contraindicated
Epilepsy Not contraindicated, consider concomitant
liver enzyme inducer and osteoporosis risk
in phenytoin and gastroenterologists
Liver Diseases Transdermal route preffered, liaise with
gastroenterologists

53. Condition Hormone Therapy
Gall bladder
disease
Increased risk of gall bladder disease
Hyperlipidemia Not contraindicated, route depends on lipid
profile
Hypertension Not contraindicated, no worsening of
control
Valvular heart
disease
Not contraindicated
Venous
Thromboembol
ism
Vaginal estrogen not contraindicated

54. Condition Hormone Therapy
Malignant
melanoma
No association from epidemiological studies
Migraine Not contraindicated, transdermal route
preferred
Otosclerosis Insufficient evidence to contraindicated
Parkinson’s
disease
May reduce risk of Parkinson’s disease, not
contraindicated
Renal Failiure Should be considered, increase risk of early
menopause

55. Condition Hormone Therapy
Post transplant Should be considered, increase risk of
osteoporosis
Rheumatoid
Arthiritis
Increase risk of osteoporosis, increase in
‘flares’
Systematic
lupus
erythematosus
Increase risk of osteoporosis, increase in
‘flares’
Thyroid
disease
Increase risk of osteoporosis, not
contraindicated

57. ADDRESS
11 Gagan Vihar, Near Karkari Morh Flyover,
Delhi - 51
CONTACT US
9650588339 (Helpline)
011-22414049,22058865
WEBSITE :
www.drshardajain.in
www.lifecarecenreivf.com
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info@lifecareivf.com
ISO 14001:2004 (EMS)
…..Caring hearts, healing hands
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